What are the management options for weight loss and breakthrough bleeding associated with Nexplanon (etonogestrel)

Management of Weight Loss and Breakthrough Bleeding with Nexplanon

For patients experiencing weight loss and breakthrough bleeding with Nexplanon (etonogestrel implant), first-line management includes short-term hormonal treatment with low-dose combined oral contraceptives for 10-20 days during bleeding episodes, while providing reassurance about the common and generally non-harmful nature of these side effects. 1

Understanding the Issue

Nexplanon is a single-rod implant containing etonogestrel, the active metabolite of desogestrel, with a failure rate of less than 1% and protection lasting up to 3 years 1. While highly effective, it commonly causes changes in bleeding patterns:

• 22% of users experience amenorrhea
• 34% experience infrequent spotting
• 7% report frequent bleeding
• 18% report prolonged bleeding 1

Weight changes with hormonal contraceptives are variable. While a Cochrane review demonstrated weight gain with medroxyprogesterone acetate injections, there is less clear evidence regarding weight changes with implants like Nexplanon 1.

Evaluation of Breakthrough Bleeding

Before initiating treatment, consider:

1. Rule out underlying gynecological problems:

   • Medication interactions
   • Sexually transmitted infections
   • Pregnancy
   • Pathologic uterine conditions (polyps, fibroids) 1

2. Assess bleeding pattern:

   • The bleeding pattern during the first three months broadly predicts future patterns
   • Women with favorable initial patterns tend to maintain them
   • Those with unfavorable patterns have at least a 50% chance of improvement 2

Management Algorithm for Breakthrough Bleeding

First-Line Options:

• NSAIDs for short-term treatment (5-7 days) during days of bleeding 1

  • Example: Ibuprofen 600-800mg every 6-8 hours with food

• Hormonal treatment with low-dose COCs or estrogen for short-term treatment (10-20 days) during days of bleeding 1

  • Studies show significant cessation of bleeding within 7 days of treatment with:
    • Oral celecoxib (200mg daily for 5 days)
    • Oral mefenamic acid (500mg 3 times daily for 5 days) 1

If Bleeding Persists:

• Provide enhanced counseling about expected bleeding patterns
• Reassure that bleeding irregularities are generally not harmful 1
• If bleeding remains unacceptable to the patient, discuss alternative contraceptive methods 1

Management of Weight Loss

Weight loss is not commonly reported with Nexplanon, but for patients concerned about weight changes:

1. Assess nutritional status:

   • Ensure adequate caloric intake (1,200-1,500 kcal/day for women) 1
   • Evaluate for adequate calcium (1300mg) and vitamin D (600 IU) daily 3

2. Consider alternative contraceptive options if weight loss is severe or concerning:

   • Barrier methods
   • Copper intrauterine devices
   • Other hormonal methods 1, 3

Patient Counseling Points

• Bleeding changes with Nexplanon are common and generally not harmful 1
• The bleeding pattern may improve over time 2
• Weight changes are variable among hormonal contraceptive users 1
• Nexplanon remains one of the most effective contraceptive methods available (>99% effective) 1, 3

Follow-Up Recommendations

• No routine follow-up visit is required specifically for Nexplanon 1
• At other routine visits:
  • Assess satisfaction with the contraceptive method
  • Evaluate any health status changes
  • Assess weight changes if the patient is concerned 1

Common Pitfalls to Avoid

1. Failing to provide adequate pre-insertion counseling about potential bleeding changes, which can improve continuation rates 1, 2

2. Immediately removing the implant due to bleeding irregularities without trying management strategies first

3. Overlooking serious underlying causes of abnormal bleeding that may require specific treatment

4. Not recognizing that the bleeding pattern during the first three months often predicts future patterns 2

5. Assuming weight changes are always directly related to the contraceptive method rather than considering other factors

If breakthrough bleeding persists despite management attempts and the patient finds it unacceptable, alternative contraceptive methods should be discussed and offered 1.